SG: Case Study Lindsay Dvorak Joel Fruchtnicht Katie Kampen Victoria Souhlas Stephanie Spann

Background Information 72 y/o Male history of tobacco chewing and smoking Pt was admitted to the hospital in Meerut India, on December 15, 2000

Symptoms Pt reported: Progressive hoarseness loss of appetite weight loss difficulty in swallowing solid foods in the last 6 months pain in the right ear and pain in the right side of the neck below the mandible in the last 4 months pt was unable to swallow solid foods 15 days prior to admission As soon as he ate solid food, he immediately vomited out with a coughing reflex (blood stained)

Upon admission.. pt presented with: Significant difficulty in swallowing solid foods hoarseness of voice complaint of pain in the right ear and right side of neck below the mandible A physical examination revealed enlarged cervical lymph nodes on right side of neck

Signs and Symptoms Head and Neck Cancer seen in SG Change in voice (hoarse) Difficulty swallowing; dysphagia Enlarged cervical lymph nodes Ear pain Weight loss and loss of appetite Vomiting with traces of blood Other signs to check for include: lump in the neck a broadening of the larynx tenderness in the neck dyspnea- difficulty breathing hoarseness is one of the first cancer symptom for cancer in the larynx

Referral After examination in the hospital a referral was made to the ENT for Laryngoscopic examination

Anatomical Signs Pharyngoscopy and laryngoscopy are often used to check for signs of head and neck cancer A physician (ENT) will perform the procedure to determine presence and to what extent of cancer is present Severity and type identified by the Tumor Classification System http://www.cancercenter.com/head-and-neck-cancer/indirect-pharyngoscopy-and-laryngoscopy/

Tumor Classification System T- Tumor Size - T1 (smallest)- T4 (largest) M- Presence or absence of Metastesis outside the region N- Nodal Status- # of nodes thought to be involved with the tumor Larynx is divided into 3 areas: Supraglottis Glottis Subglottic The extent of effects will depend on the site and size of the tumor

Suspected Anatomy of SG Cancer is one of the diseases that may affect the anatomy and structures of the oral cavity, pharynx and larynx If a malignant lesion affects one or both vocal folds directly, hoarseness will result due to invasion of the tumor on the structures The magnitude will depend on the extent and site of the carcinoma

Observable Physiological Signs Laryngoscopic examination may reveal anything from a small, well- defined tumor to a large and diffuse tumor involving any part of the larynx or vocal folds As the severity of the lesion increases it becomes more invasive which negatively affect vibratory vocal fold behavior Lesion can cause the vocal folds to become stiff which would affect the mucosal wave and amplitude of vibration

Measurable Physiological Signs With large tumors, airflows are generally increased due to large leakage flows because the tumors can prevent vocal fold closure Mean airflow rates can increase Subglottal air pressures may be increased because of the increased stiffness of the vocal folds

Here’s why... Cancerous lesions invade the tissue and destroy normally behaving cells Invasion of the tumor into the various levels of the lamina propria and muscle results in greater stiffness of the tissue resulting in reduced horizontal excursion of the affected fold and often of the contralateral fold and restricted or absent mucosal wave prevents vocal fold closure A variety of benign and malignant tumors may be found in the laryngeal or neck region Such tumors may obstruct the airway directly or may occupy space and place pressure on the trachea or larynx

Dysphagia Depending on site and lesion, the obstruction of a tumor could result in oropharyngeal dysphagia If the tumor is located near the vocal folds, it can impede on airway closure resulting in pharyngeal dysphagia

Respiratory System The respiratory system would need to be assessed due to: Increased risk for respiratory dysfunction and anatomical changes due to history of smoking and complaints of voice disorder Enlarged lymph nodes can also be indicative of an Upper Respiratory infection or cancer affecting the lungs and/or respiratory system

Effects of Smoking Tobacco on Respiratory System Irritation of the trachea and larynx reduced lung function and breathlessness due to swelling and narrowing of lung airways impairment of lungs’ clearing system resulting in lung irritation and damage increased risk of lung infection and symptoms such as coughing and wheezing permanent damage to air sacs of the lungs can cause cancer of the lungs, esophagus, larynx, mouth, throat and more http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Smoking_effects_on_your_body

Lymphadenopathy Enlarged Lymph nodes Lymph nodes filter the lymphatic fluids on its way to central venous circulation, removing cells and other materials Pathogenic microorganisms carried in the lymphatic fluid can directly infect the lymph nodes Because lymph nodes participate in the bodys’ immune response, a large number of infectious and inflammatory disorders and cancers are potential causes Leading causes of enlarged lymph nodes include: Idiopathetic, self limited (no known cause) Upper Respiratory Infection Cancer (lung, gastrointestional, retropertineal) May be able to see enlarged nodes, pt may report feeling a lump in the neck region, or slp/RN/MD may find lump upon palpation http://www.merckmanuals.com/professional/cardiovascular-disorders/lymphatic-disorders/lymphadenopathy

Lymphatic Drainage System How much of normal tissue resected in a head and neck cancer patient is determined by the site of malignancy The lymphatic drainage system is a series of vessels that drain fluid from cells Depending on the way the system drains, it could determine the way in which the tumor spreads For example, because of the way the lymphatic system drains in the supraglottic larynx, a tumor in that area will not spread downward to the TVF and/or subglottic larynx unless the tumor is at the base of the epiglottis So it is important to note where and to what extent a tumor has spread to in order to see what changes can be expected anatomically “Evaluation and Treatment of Swallowing Disorders” Jeri Logemann

Following ENT consult... -MBSS to assess anatomy and physiology of swallowing -Assess respiratory patterns -Assess voice production